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Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-dimer

Philip S. Wells, MD, MSc; David R. Anderson, MD; Marc Rodger, MD, MSc; Ian Stiell, MD, MSc; Jonathan F. Dreyer, MD; David Barnes, MD; Melissa Forgie, MD; George Kovacs, MD; John Ward, MD; and Michael J. Kovacs, MD
[+] Article and Author Information

From the University of Ottawa, Ottawa, and University of Western Ontario, London, Ontario; Dalhousie University, Halifax, Nova Scotia; and University of British Columbia Vancouver, British Columbia, Canada.


Grant Support: By a grant from the Heart and Stroke Foundation of Nova Scotia and Ontario grant NA 3304. Dr. Philip Wells is a recipient of a Canada Research Chair; Dr. Stiell is a recipient of a Distinguished Scientist Award from the Canadian Institute of Health Research; Dr. Anderson is a Research Scholar of Dalhousie University; and Dr. Kovacs is an Internal Scholar of the Department of Medicine, University of Western Ontario.

Requests for Single Reprints: Philips P. Wells, MD, MSc, Suite 452, 737 Parkdale Avenue, Ottawa, Ontario K1Y 1J8, Canada.

Current Author Addresses: Drs. Wells and Forgie: Division of Hematology, The Ottawa Hospital, Civic Campus, Suite 452, 737 Parkdale Avenue, Ottawa, Ontario K1Y 1J8, Canada.

Dr. Anderson: Division of Hematology, Queen Elizabeth II Health Science Centre, Bethune Building, Room 432, Victoria General Hospital Site, 1278 Tower Road, Halifax, Nova Scotia B3H 2Y9, Canada.

Drs. Barnes and G. Kovacs: Division of Hematology, Queen Elizabeth II Health Science Centre, Bethune Building, Victoria General Hospital Site, 1278 Tower Road, Halifax, Nova Scotia B3H 2Y9, Canada.

Dr. Rodger: Division of Hematology, The Ottawa Hospital General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.

Dr. Dreyer: London Health Sciences Centre, Victoria Campus, Box 5375 Station B, London, Ontario N6A 4G5, Canada.

Dr. Stiell: Emergency Department, The Ottawa Hospital Civic Campus, 1053 Carling Avenue, Ottawa, Ontaio K1Y 4E9, Canada.

Dr. Ward: Emergency Department, St. Paul's Hospital, 1081 Burrand Street, Vancouver, British Columbia V6Z 1Y6, Canada.

Dr. M. Kovacs: Department of Hematology, University of Western Ontario, 800 Commisioners Road East, London, Ontario N6A 4G5, Canada.

Author Contributions: Conception and design: P.S. Wells, D.R. Anderson, I. Stiell, J.F. Dreyer, M.J. Kovacs.

Analysis and interpretation of the data: P.S. Wells, D.R. Anderson, M. Rodger, I. Stiell, M. Forgie, M.J. Kovacs.

Drafting of the article: P.S. Wells, D.R. Anderson, M. Rodger, I. Stiell, J.F. Dreyer, D. Barnes, M. Forgie, J. Ward.

Critical revision of the article for important intellectual content: P.S. Wells, D.R. Anderson, M. Rodger, D. Barnes, M. Forgie, G. Kovacs, J. Ward, M.J. Kovacs.

Final approval of the article: P.S. Wells, D.R. Anderson, M. Rodger, I. Stiell, D. Barnes, M. Forgie, G. Kovacs, J. Ward, M.J. Kovacs.

Provision of study materials or patients: P.S. Wells, D.R. Anderson, M. Rodger, I. Stiell, D. Barnes, M. Forgie, G. Kovacs, J. Ward, M.J. Kovacs.

Statistical expertise: P.S. Wells.

Obtaining of funding: P.S. Wells, D.R. Anderson, G. Kovacs.

Administrative, technical, or logistic support: P.S. Wells, J.F. Dreyer, G. Kovacs, M.J. Kovacs.

Collection and assembly of data: P.S. Wells, D.R. Anderson, M.J. Kovacs.


Ann Intern Med. 2001;135(2):98-107. doi:10.7326/0003-4819-135-2-200107170-00010
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Pulmonary embolism is a relatively common disease, with an estimated annual incidence in the United States of 23 cases diagnosed per 100 000 persons (1). More than 50% of cases are undiagnosed. Untreated pulmonary embolism has a high mortality, although risk for death is reduced significantly with anticoagulation (2). Because the clinical signs and symptoms of pulmonary embolism are not specific, timely diagnostic testing must be done to confirm the diagnosis. Ventilation-perfusion lung scanning is the most common imaging procedure for suspected pulmonary embolism. However, the result is frequently nondiagnostic, and additional testing is needed to confirm a diagnosis. Patients presenting to the emergency department with suspected pulmonary embolism present a challenge, particularly if diagnostic testing is not immediately available.

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Figure 1.
Diagnostic algorithm for initial evaluation of patients with suspected pulmonary embolism.

Plus and minus signs indicate positive and negative test results, respectively. DVT = deep venous thrombosis; PE = pulmonary embolism; VQ = ventilation-perfusion lung scan.

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Grahic Jump Location
Figure 2.
Algorithm for patients with suspected pulmonary embolism.dd

Plus and minus signs indicate positive and negative test results, respectively. * Two patients had pulmonary embolism diagnosed according to high-probability ventilation-perfusion scanning, which had been done despite a negative -dimer test result. † Deep venous thrombosis on day 46. ‡ Deep venous thrombosis on day 11 in a patient with high clinical pretest probability. § One patient had no -dimer testing and showed pulmonary embolism on spiral computed tomography. CT = computed tomography; DVT = deep venous thrombosis; PE = pulmonary embolism; VQ = ventilation-perfusion lung scan.

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Summary for Patients

Improving the Diagnosis of Pulmonary Embolism in the Emergency Department

The summary below is from the full report titled “Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-dimer.” It is in the 17 July 2001 issue of Annals of Internal Medicine (volume 135, pages 98-107). The authors are PS Wells, DR Anderson, M Rodger, I Stiell, JF Dreyer, D Barnes, M Forgie, G Kovacs, J Ward, and MJ Kovacs.

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